GW1--05780_Well Construction - GW1_20230905

I1 1111L I.Vl III_.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Ti-Y1lIrce"Y1 1 kson •1.4.WATER-ZONES=. ,..`.;._.:',.:'1-',.=.:.•-. - .
Well Contractor Name FROM To DESCRIPTION
�� p ft. .F.2V ft J
40)1 o m
ft. ft.
NC Well Contractor Certification Number 15:':Oi)TER CASING-(foi•-muttl=csieil`tivells)'OR LINER-Cif an livable)"- "-r' "'
Icy/_�}^ �`� / FROM TO DIAMETER THICKNESS MATERIAL
/(/L JQ J Ie ft. it. in.
Company Name ':16.:INNER CASING OR TUBING.(geothermal closed-loopy- - - ..
2.Well Construction Permit#: 02 0 a -- GO 5 0)9 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0 ft. 5g ft. 6 75- in. s-D)2 2 l �/,p v
3.Well Use(check well use): ft. ft in.
Water Supply Well: .17:SCREEN`= '.-. .:-_.-- .- "-;'1€:::.$ >,;._ _ --_- -- _ -
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL.
*Agricultural OM tpal/Public ft. ft. In.'
a Geothermal(Heating/Cooling Supply) ge'esidential Water Supply(single) ft ft
*ilndustrial/Conunercial °Residential Water Supply(shared) ,'1&:_GROUT
is'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOIINT
Non-Water Supply Well: 0 ft.- 02 v ft." 'Blue.-
*'Monitoring °Recovery ft. ft. ele.‘I
Injection Well: ft ft.
ai Aquifer Recharge IDGroundwater Remediation
=.19.'SAND/GRAVEL TACK(if applicable)''..':-:Z-.,. .":_a .: 'j'_'. _=:. :`, ...
III Aquifer Storage and Recovery f°SalinityBarrier FROM TO MATERIAL EMPLACEMENT METHOD
**Aquifer Test (Stormwater Drainage ft. ft.
*Experimental Technology Subsidence Control ft. ft. ,',
Geothermal Closed Loo I_,Tracer 10:-DRILLING.L•OG attachsdditionalslieets.ifnecessa '
FROM. TO DESCRIPTIONS color.hardness,soil/rack type,grain size,etc.)
I Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ft. �� ft. L/' 0 t��J� 4_ �� e
4.Date Well(s)Completed: 5--$-Z3 Well ID# cct ft- f ©eft G r(/h :4-e-
ft.5a.Well Location:
ft G�c
ft. ft.
t.- 9
Facility/Owner Name/ Facility lD#(if applicable) ft. f• L j �, ,y
5 sit o¢11-2tss tn. tie. x, ruc_�,?s�3a ft. ft SEP 0 5 ?023
Physical Address,City, d Zip ft. ft.
lzcr -;:-a
ti a211 vARxs: ,B �. r4. . . ,
�
t& \C IA. e cta(o 103 ,33G0b , Err IJa}(p
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C ' cation:
jS's' 7. ` 311.5 233 eeN gd c),,W' 47. 71 J 7 41 't w 2-Q?3
6.Is(are)the well(s) ermanent or EtTemporary ignature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or N o with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional'well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: RrrulvrTr-rAT.INIRTItUCTIONC
9.Total well depth below land surface: I I 0 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(4100') construction to the following: I 1 a
10.Static water level below top of casing: a eD (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: is' Z S. (in.) 24b.For Iniection Wells: In'addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: O`�CZ construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 i a
Method of test: G'G I. (.fM 14 We. 24c.For Water Sunplv&Injection Wells: In addition to sending the form to
/�t1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l J I -tj"Q- Amount: I oZ. �I--S completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22_21)1 t: